UC-NRLF 


O 


UNIVERSITY  OF  CALIFORNIA. 

FROM  THE   LIBRARY  OF 

DR.  JOSEPH  LECONTE. 

GIFT  OF  MRS.  LECONTE. 


• 


A 

POCKET    MANUAL 

OF 

PERCUSSION!  AUSCULTATION 

FOB 

PHYSICIANS  AND  STUDENTS. 

TRANSLA  TED  FROM  THE  SECOND  GERMAN  EDITION 

BY  J.  O.  HIRSCHFELDER. 


SAN  FBANCISCO: 
A.    L.    BANCKOFT    &    COMPANY, 

PUBLISHEKS,  BOOKSELLEES  &  STATIONEES. 
1873. 


Entered  according  to  Act  of  Congress,  in  the  year  1872, 

BY  A.  L.  BANCROFT  &  COMPANY, 
In  the  office  of  the  Librarian  of  Congress,  at  Washington. 


TRANSLATOR'S    PREFACE. 


HOWEVER  numerous  the  works  that  have  been  previously 
published  in  the  English  language  on  the  subject  of  Per- 
cussion and  Auscultation,  there  has  ever  existed  a  lack  of 
a  complete  yet  concise  manual,  suitable  for  the  pocket* 

The  translation  of  this  work,  which  is  extensively  used 
in  the  Universities  of  Germany,  is  intended  to  supply  this 
want,  and  it  is  hoped  will  prove  a  valuable  companion  to 
the  careful  student  and  practitioner. 

J.  0.  H. 

SAN  FRANCISCO,          \ 
November,  1872.  f 


1152 


PERCUSSION. 


FOR  the  practice  of  percussion  we  employ  a 
pleximeter,  or  a  finger,  upon  which  we  strike 
with  a  hammer,  or  a  finger,  producing  a  sound, 
the  character  of  which  varies  according  to  the 
condition  of  the.  organs  lying  underneath  the 
spot  percussed. 

In  order  to  determine  the  extent  of  the  sound 
produced,  we  may  imagine  the  following  lines 
to  be  drawn  upon  the  chest :  (1)  the  mammary 
line,  which  begins  at  the  union  of  the  inner 
and  middle  third  of  the  clavicle,  and  extends 
downwards  through  the  nipple;  (2)  the  paraster- 
nal  line,  which  extends  midway  between  the 
sternum  and  nipple ;  (3)  the  axillary  line,  which 
extends  from  the  centre  of  the  axilla  to  the  end 
of  the  llth  rib.  Upon  the  back  we  percuss  in 
a  line  running  parallel  with  the  spinal  column, 
and  according  to  the  various  regions,  regio  supra, 
spinata,  scapularis  and  infra  scapular  is.  For  the 
percussion  of  the  abdomen,  the  linea  alba  and 
the  known  anatomical  regions,  are  taken  into 
consideration. 


D  PEKCUSSION. 

Percussion  Sounds- 

[By  the  percussion  of  a  portion  of  the  surface  of  the  body, 
we  obtain  either  a  dull  sound,  or  one  varying  in  its  intensity, 
pitch,  duration  and  timbre.] 

DULL  SOUND. 

This  always  arises  from  the  blow  alone,  when- 
ever the  subjacent  organ  does  not  possess  suffi- 
cient elasticity  to  produce  audible  vibrations, 
and  the  percussion  impulse  is  not  transmitted 
through  it  to  more  elastic  parts.  The  necessary 
vibratory  power  is  lacking  in  all  parts  not  con- 
taining air,  and  in  all  fluids.  The  dull  sound 
therefore  shows  that  there  is  underneath  the 
percussed  spot,  liver,  heart,  spleen,  new  forma- 
tion not  containing  air,  uterus,  distended  blad- 
der, stomach  filled  with  fluid,  hepatized  lung, 
(or  one  emptied  of  its  air  by  compression,)  or 
bloody,  purulent,  or  serous  fluid.  The  nature  of 
these  parts  cannot  be  distinguished  through  per- 
cussion, be  they  constituted  in  anyway  whatever, 
hard  or  soft,  free  or  enclosed.  But  where,  on  the 
other  hand,  the  above  parts  border  upon  organs 
containing  air,  which  give  no  dull  sound,  we 
can  specify  their  extent  with  great  accuracy. 

SONOEOUS  SOUND. 

The  sonorous   sound   is   produced   whenever 


PERCUSSION  SOUNDS.  7 

sufficiently  elastic  parts  receive  the  percussion 
impulse.  Such  elastic  parts  are  tense  membranes, 
and  air  or  gas,  the  latter  when  in  enclosed 
cavities  so  that  permanent  waves  are  formed. 

The  sonorous  sound  shows,  since  the  mem- 
brane can  be  made  tense  only  through  air  or 
gas,  that  one  of  these  exists  under  the  per- 
cussed spot. 

The  sonorous  sound  is  either  tympanitic  or 
noii-tympanitic.  We  call  a  sound  tympanitic 
when  it  approaches  a  musical  note  and  shows  a 
musically  determinable  pitch;  when  in  other 
words  it  is  not  a  mere  noise  but  a  real  tone. 

TYMPANITIC  SOUND. 

This  always  occurs  whenever  the  formation  of 
uniform  and  regular  permanent  sound  waves  is 
possible. 

All  the  sonorous  cavities  in  the  thorax  and 
abdomen  are  limited,  and  consequently  allow 
the  formation  of  permanent  waves. 

Regular  wave  systems  are  possible  in  the  tho- 
rax and  abdomen,  however,  under  the  given 
conditions  only,  when  the  sound  is  produced  by 
the  air  alone.  This  takes  place  when  the  air  is 
enclosed  by  walls  which  are  not  sufficiently  tense 
to  be  capable  of  audible  vibrations,  but  which 


8  PERCUSSION. 

can  merely  reflect  them.  As  soon  as  they  be- 
come so  tense,  that  they  can  also  produce  audible 
vibrations,  the  sound  waves  become  irregular 
through  the  spherical  tension  of  the  walls  en- 
closing the  air,  and  the  percussion  sound  be- 
comes non-tympanitic,  or  a  mere  noise. 

The  tyinpanitic  sound  therefore  shows,  that 
under  the  percussed  spot  air  spaces  exist  with 
walls  not  sufficiently  tense;  such  are: 

1.  Either    normal    or    pathological  cavities, 
completely    or    partially  filled  with  air,  whose 
walls   are  not  too  strongly  stretched:  such  are 
the  stomach,  intestine,  cavities,  Pneumothorax, 
Tympanites  Peritonialis. 

2.  A  portion  of  lung,    whose  cells  and  bron- 
chial walls  have  lost  their  normal  tension  through 
loss  of  their  elasticity  and  contractility  (power 
of   retraction),    or    through    compression    to    a 
smaller  volume,  so  that  the  power  of  retraction 
can  be  no  longer  exercised. 

NON-TYMPANITIC  SOUND. 

This  always  occurs  whenever  audible  vibration 
of  air-enclosing  walls,  such  as  lung  parenchyma, 
stomach,  intestinal  or  chest  walls,  is  possible. 
It  therefore  shows  a  certain  amount  of  tension 
in  the  above  mentioned  parts. 


{   WNIV 

PERCUSSION   SOUNDS.  9 

We  obtain  tympanitic  sounds : 

(a)  Under  normal  circumstances  in  the  region 
of  the  stomach  and  intestinal  tube,  as  long  as 
these  contain  air  or  gas,  and  their  walls  and 
those  of  the  abdomen  are  not  too  tense.  The 
non-tympanitic  sound  of  this  region  is  therefore 
abnormal,  and  shows  either  an  entire  filling  of 
the  above  organs  with  fluid,  or  a  change  produced 
in  them  by  solid  organs  or  fluids;  or,  finally, 
unusual  tension  of  the  walls,  as  in  Meteorism. 

(6)  Under  abnormal  circumstances  it  is  pos- 
sible at  every  point  of  the  thoracic  or  abdomin- 
al walls:  1,  above  free  air  in  the  thoracic  or  ab- 
dominal cavity  in  Pneumothorax  or  Tympanites 
Peritonialis;  2,  above  superficial  air  cavities  and 
dilated  bronchial  tubes,  when  it  is  alterable  in 
pitch  by  opening  and  closing  the  mouth;  3,  over 
air-containing  parts  of  the  lung  whose  vesicles 
have  lost  their  tension  from  acute  exudation 
into  them  without  compression  of  the  air,  as  in 
acute  (Edema,  acute  Hillary  Tuberculosis  and 
incipient  Pneumonia.  It  may  be  produced  by 
rapidly  arising  Emphysema  (around  infiltrations), 
sometimes  also  by  chronic  Emphysema,  when  it  is 
equally  spread  over  a  large  number  of  vesicles,  or 
by  compression  of  the  entire  lung,  as  above  pleuri- 
tic exudations,  Emphysema,  or  Hydrothorax. 


10  PERCUSSION. 

Normal  lung  never  sounds  tympanitic,  as  long 
as  its  tissue  is  contractile.  The  stomach  and 
intestines,  Pneumothorax  and  Tympanites,  no 
longer  sound  tympanitic  when  the  former  be- 
come so  distended,  or  the  latter  so  considerable 
that  the  thoracic,  intestinal,  or  abdominal  walls 
become  tightly  stretched. 

The  sonorous  sound,  most  plainly  the  tym- 
pauitic  but  also  the  non-tympanitic,  shows  differ-  , 
ences  important  for  diagnosis : 

(1.)  According  to  the  size  of  the  vibrating 
mass  of  air,  the  sound  is  full  and  long,  or  empty 
and  short. 

Wherever  parts  of  similar  character,  capable 
of  vibration,  take  up  a  greater  space,  the  sound 
waves  produced  being  therefore  longer,  the 
blow  gives  a  fuller,  longer,  deeper  sound,  if  it  is 
strong  enough  to  spread  the  impulse  sufficiently. 
The  less  the  extent  of  the  part,  the  higher  and 
shorter  is  the  percussion  sound. 

That  the  elasticity  of  the  vibrating  part  influ- 
ences the  duration  of  the  tone  (its  volume)  is  a 
matter  of  course. 

Healthy  lung,  Pneumothorax,  and  distended 
stomach  sound  full.  Generally  eniphysematous 
lungs  sound  fuller  than  normal ;  intestines  and 
cavities  in  tissue  not  containing  air,  shorter. 


PERCUSSION   SOUNDS.  11 

Small  superficial  cavities  and  thin  layers  of  lung 
not  containing  air,  as  the  lower  border  of  the 
right  lung  and  the  inner  of  the  left,  sound  very 
short  and  empty.  The  stomach  and  duodenum 
sound  tympanitically  full,  and  the  small  intes- 
tines tynipanitically  short.  Incipient  Pneumo- 
nia, acute  (Edema  of  an  entire  lung,  sound 
tympanitically  full;  and  partial  Emphysema 
around  a  hepatized  part  of  the  lung,  tympaniti- 
cally short. 

"With  the  tympanitic  sound  all  these  differences 
are  recognized  as  variations  of  the  musical  pitch 
of  the  tone.  Yet  the  size  of  the  vibrating  part 
cannot  always  be  determined  by  the  absolute 
degree  of  the  fullness  or  shortness  of  a  percus- 
sion sound,  as  comparison  with  other  spots  is 
alone  of  value. 

(2.)  According  to  the  nature,  thickness,  re- 
sistence  and  conductivity  of  the  medium  conduct- 
ing the  percussion  impulse,  the  sound  is  either 
clear  or  dull. 

Wherever  a  thicker  layer  of  medium,  which 
does  not  sound,  lies  between  the  percussion 
stroke  and  the  mass  of  air  set  into  vibration, 
and  the  impulse  (as  well  as  the  vibrations  pro- 
duced) is  badly  conducted,  the  percussion  sound 
produced  becomes  duller.  Air  spaces  immedi- 


12  PERCUSSION. 

ately  behind  an  elastic  chest-wall,  which  is  not 
too  fleshy,  or  behind  the  epigastrium,  alone 
sound  fully  clear. 

The  muffler*  of  a  percussion  sound  may 
be  situated  in  the  percussed  medium,  or  in  the 
chest  or  abdominal  wall  itself.  The  conductivity 
may  be  interfered  with  by  adjacent  non-elastic 
parts,  or  non-sounding  mediums  may  have  been 
interposed  between  the  thoracic  or  abdominal 
walls  and  the  sonorous  space.  The  sound  may 
be  muffled  by  those  parts  of  the  subjacent  or- 
gans, immediately  beneath  the  point  of  impulse, 
becoming  empty  of  air  which  they  normally 
contain. 

A  thick  pleximeter,  strong  ribs  or  ossification 
of  their  cartilages,  or  greater  convexity  than  com- 
mon, fleshy  thoracic  or  abdominal  walls,  tension 
of  the  muscles,  (Elemaand  other  swellings,  and 
solid  organs  or  fluids  lying  against  them,  muffle 
the  sound  of  the  lung  and  the  abdominal  organs 
containing  air.  The  borders  of  the  liver  muffle 
the  sound  of  the  stomach  and  colon  lying  behind 
them.  Great  thickening  of  the  pleura  after  Pleu- 
ritis,  and  exudations  into  the  pleural  sac,  as  long 

*Tke  muffl  3r  is  that  which  deadens  the  percussion  sound. 
Its  activity  is  in  inverse  proportion  to  the  strength  of  the  blow. 


PERCUSSION   SOUNDS.  13 

as  they  do  not  exclude  all  the  air,  deaden  the  lung 
sound.  In  a  similar  manner  inflammatory  or 
dropsical  transudations  into  the  peritoneum 
deaden  the  intestinal  sound.  Great  thickening 
of  the  walls  of  the  stomach  and  intestines  has 
the  same  effect.  Superficial  hepatization  of  the 
lung  operates  similarly,  while  the  same  changes 
in  parts  situated  .more  deeply  merely  shorten, 
not  deaden,  the  percussion  sound. 

There  are  many  changes  of  the  lungs  which 
lessen  the  elasticity,  the  conduction  of  the  im- 
pulse, and  the  vibrations  at  the  same  time.  In 
these  cases  the  sound  becomes  simultaneously 
shorter,  weaker  and  duller. 

Chronic  (Edema  of  the  lung  and  Tubercular 
Infiltration,  with  small  cavities  which  do  not 
communicate,  shorten  and  deaden  the  sound. 

(3.)  Peculiar  modifications  of  the  sound  are 
the  following: 

(a)  The  metallic  percussion  sound  (son  hydro- 
pneumatique — Piorry).  This  exists  only  over  large 
air  spaces,  whenever  the  sound  waves  are  regu. 
larly  reflected  from  two  points  of  the  surroun- 
ding wall,  so  that  through  interference  independ. 
ent  sounds  are  formed.  This  takes  place  whether 
the  space  gives  a  tympanitic  sound  or  not,  i.  e. 
whether  the  walls  are  tense  or  not.  It  occurs 


14  PERCUSSION. 

only  over  a  stomach  containing  air,  or  over  very 
large  cavities,  or  in  Pneumothorax. 

(b)  Cracked  metal  sound  (Bruit  de  pot  file). 
This  may  be  imitated  by  percussion  upon  the 
hand  placed  over  the  ear.  It  occurs  over  a 
large  superficial  cavity  communicating  with  a 
bronchus,  or  over  a  dilated  bronchial  tube,  and 
arises  from  the  fact  that  by  a  strong  blow  the 
cavity  becomes  somewhat  compressed  and  the 
contained  air  empties  into  the  bronchus,  pro- 
ducing a  w^hizzing  noise,  and  this  mingles  with 
the  ordinary  short  and  tympanitic  sound  of  the 
cavity. 

Opening  the  mouth  usually  assists  in  produc- 
ing this  phenomenon.  A  very  strong  stroke  in 
percussing,  especially  in  the  infantile  thorax, 
produces,  by  its  compression,  an  analogous 
wheezing  occasioned  by  the  forcible  expulsion  of 
air.  This  may  also  be  obtainedfrom  healthy  lungs. 

In  complete  compression  of  one  lung  by  fluid 
pleuritic  exudations  we  sometimes  hear  a  very 
short  metallic,  ringing,  cracked-pot  sound  (sound 
of  rattling  coin)  in  the  region  of  the  large 
bronchi  upon  strong  and  short  percussion. 

The  hydatid  tone  of  Piorry,  represented  by 
him  as  being  perfectly  characteristic  of  Echino- 
coccus-sacs,  is  probably  only  a  feeling  of  fluctu- 
ation in  percussing. 


PERCUSSION  OF  THE  ORGANS.        15 

Percussion  of  the  Organs. 
By  means  of  the  distinction  between  the  dull 
and  sonorous  sounds  we  can  determine  the  nor- 
mal area  of  the  organs  of  the  chest  and  abdo- 
men. 

LUNGS. 

The  area  of  the  lungs  in  the  average  man  is  as 
follows : 

The  apices  of  the  lungs  are  percussed  in  the 
supraclavicular  fossa  close  to  the  origin  of  the 
Sterno-cleido-mastoideus. 

The  right  lung  extends  downwards  in  the  par- 
asternal  line  to  the  union  of  the  sternum  with 
theensiform  process,  in  the  mammary  line  to  the 
upper  border  of  the  6th  rib,  in  the  axillary  line 
to  the  upper  border  of  the  8th  rib,  and  behind, 
at  the  spinal  column,  to  the  eleventh  rib.  In  the 
median  line  it  extends  toward  the  left  almost  to 
the  border  of  the  sternum,  where  the  border  of 
the  right  lung  together  with  that  of  the  left,  passes 
downwards  to  the  fourth  intercostal  space,  and 
then  obliquely  toward  the  right  to  the  above- 
mentioned  point  in  the  paras ternal  line. 

HEART. 

The  size  of  the  heart  is  determined  through 
the  dull  percussion  sound  which  is  given  by 


16  PERCUSSION. 

that  portion  immediately  in  contact  with  the 
chest  and  not  covered  with  lung  tissue,  forming 
the  so  called  cardiac  vacuum.  Some  observers 
seek  to  determine  its  size  by  the  "cardiac  dull- 
ness,'" which  is  heard  at  those  places  where  the 
borders  of  the  lung  cover  the  heart. 

The  cardiac  dullness,  determinable  through 
strong  and  deep  percussion,  forms  upon  the 
chest-wall  a  triangular  figure  with  blunt  apex 
and  somewhat  convex  sides. 

The  upper  angle  lies  at  the  union  of  the  3d 
left  costal  cartilage  with  the  sternum.  The 
right  angle  lies  over  the  sixth  rib,  4c.m.*  from 
the  median  line.  The  left  angle  lies  in  the  5th 
left  intercostal  space,  where  the  apex  beat  is 
visible,  10  to  llc.m.  from  the  median  line. 

The  so-called  Cardiac  Vacuum,  (Herzleerheit) 
is  found  only  upon  weak,  superficial  percussion, 
and  is  also  described  by  a  triangle,  whose  base 
corresponds  with  that  of  the  larger  one,  whose 
apex  lies  at  the  fourth  intercostal  space,  at  the  left 
border  of  the  sternum,  whose  right  angle  lies  in 
the  median  line  at  the  upper  end  of  the  ensiform 
process,  and  wrhose  left  angle  generally  falls 
upon  the  apex  beat,  midway  between  the  mam- 

*A  centimetre  =  .3937  inch. 


ORGANS.  17 

mary  line  and  the  left  sternal  border,  but  some- 
times a  little  more  to  the  left. 

Increased  cardiac  dullness  occurs:  (1)  in  Hy- 
pertrophy and  Dilatation  of  the  heart;  (2)  inPeri- 
cardial  exudations  and  tumors;  (3)  when  the 
heart  is  forced  forward  from  behind  by  exudations 
etc.,  so  that  a  greater  surface  lies  in  contact  with 
the  chest  wall;  and  (4)  when  the  adjacent  parts 
of  the  lung  give  a  dull  sound,  as  in  pleuritic  ex- 
udations, mediastinal  tumors  and  aneurisms  of  the 
aorta.  Diminished  cardiac  dullness  occurs 
when  the  border  of  the  lungs  extends  over  the 
anterior  cardiac  area.  The  lungs  may  then  be 
either  normal  or  emphysematous. 

LIVER. 

The  dimensions  of  the  liver  must  always  be 
measured  in  cases  of  accidental  changes  of  its 
position.  We  find  that  the  upper  part  of  the 
liver  is  covered  by  the  descent  of  the  lower  bor- 
der of  the  right  lung  into  the  space  between  the 
rib  walls  and  the  diaphragm,  which  rises  ob- 
liquely upwards  and  inwards.  In  consequence 
of  this,  a  layer  of  lung  tissue,  which  gradually 
diminishes  in  thickness  from  above  downwards, 
lies  between  it  and  the  chest  wall.  The  other 
parts  of  the  liver  lie  in  contact  with  the  chest 
2 


18  PERCUSSION. 

wall.  The  highest  point  of  the  convex  surface 
of  the  liver  reaches  about  to  the  altitude  of  the 
4th  rib.  The  lower  border  lies  concealed  in 
the  right  hypogastrium  under  the  vault  of  the 
ribs  as  far  as  to  the  tenth.  From  this  point  it 
can  be  followed  obliquely  through  the  epigas- 
trium midway  between  the  navel  and  the  ensi- 
form  cartilage  towards  the  left  hypogastrium. 
Percussion,  which  should  be  very  strong  for  the 
upper  part  as  far  as  it  is  covered  by  lung,  but 
weak  for  the  lower  part,  gives  the  length  of  the 
area  of  liver  dullness : 

In  the  mammary  line  =  11  to  13  c.  m. 

11       axillary  "     "    =  12  c.  m. 

"       parasternal  "    =  10  c.  m. 
The  dullness  of  the  left  lobe  extends  sidewise 
from  7  to  8c.  m.  beyond  the  linea  alba. 

SPLEEN. 

The  spleen  lies  in  the  left  part  of  the  abdo- 
men and  runs  forward,  outward,  and  downward, 
nearly  parallel  with  the  tenth  rib,  and  under  the 
9th  intercostal  space.  In  practice  the  determin- 
ation of  its  anterior  angle  and  of  its  breadth  in 
the  linea  axillaris  is  usually  sufficient. 

Percussion  in  the  axillary  line  gives  the  extent 
of  the  spleen  under  the  ninth  or  tenth  rib  =  5 


PERCUSSION  OF  THE  ORGANS.        19 

c.  m.  The  dullness  is  bounded  inferiorly  by 
the  anterior  end  of  the  eleventh  rib,  superiorly 
by  the  ninth  rib  opposite  the  axilla,  posteriorly 
by  the  eleventh  dorsal  vertebra,  and  anteriorly 
by  an  imaginary  line  drawn  from  the  end  of  the 
eleventh  rib  to  the  nipple.  If  the  spleen  is  not 
found  in  [the  latter  line  it  is  not  enlarged,  as  a 
normal  spleen  never  extends  thus  far.  The 
spleen  is  examined  principally  by  palpation. 

Variations  of  the  extent  and  position  of  the 
above  organs  are  likewise  determined  by  means 
of  the  distinction  between  the  dull  and  the 
sonorous  sound,  provided  no  two  solid  parts 
border  upon  each  other,  or  the  air  capacity  of 
the  abdomen  is  not  affected  by  new  formations 
or  fluids,  or  the  lung  has  not  become  empty  of 
air  by  pathological  processes,  or  pushed  aside 
by  pleuritic  exudations. 

PALPATORY  PERCUSSION. 

Percussion  has  a  further  importance  as  regards 
knowledge  of  the  nature  of  the  percussed  organs, 
from  the  fact  that  we  can  take  the  feeling  of  resis- 
tance into  account  at  the  same  time.  We  practice 
palpatory  percussion  simultaneously  with  acous- 
tic percussion,  as  mediate,  or  better  alone  as  im- 
mediate percussion,  employing  one  finger  bent  in 
the  form  of  a  hook. 


20  PERCUSSION. 

The  resistance  appreciable  in  percussion  de- 
pends upon  the  nature  of  the  medium  conveying 
the  impulse.  The  thicker  and  more  unyielding 
and  inelastic  the  medium,  the  more  appreciable 
does  the  resistance  become. 

The  abdominal  and  thoracic  walls  of  children 
give  almost  no  resistance,  which  depends  alone 
upon  the  subjacent  organs.  Infiltrated  or  hepa- 
tized  lungs  increase  the  resistance  of  the  thorax; 
fluids  within  the  cavity  of  the  chest,  which 
make  the  thoracic  walls  tense  at  the  same  time, 
give  the  greatest  resistance. 

PECTORAL  OR  VOCAL  FREMITUS. 

In  the  normal  condition  of  the  respiratory  or- 
gans, the  hand  placed  directly  upon  the  thorax  of 
a  person  speaking  in  an  ordinary  tone  of  voice 
feels  trembling  movements  accompanying  those  of 
the  chest;  thisfremitus  is  as  a  rule  stronger  on  the 
right  than  on  the  left  side.  It  arises  through  the 
conduction  of  the  vibrations,  produced  in  speak- 
ing, to  a  thoracic  wall  capable  of  vibration.  The 
better  the  conduction  and  the  less  tense  the  wall, 
the  stronger  is  the  vocal  fremi^us;  the  worse  the 
conduction  and  the  more  tense  the  chest  wall, 
the  weaker  it  will  be. 

The  tension  of  the  wall   is  diminished  wher- 


PERCUSSION  OF  THE  ORGANS.        21 

ever  the  power  of  retraction  of  the  lung  becomes 
extinct,  therefore  where  tympanitic  sound  exists. 
It  is  increased  wherever  firm  or  fluid  bodies  touch 
the  wall,  that  is  where  resistance  against  percus- 
ion  diminishes,  and  also  where  it  becomes  great- 
ly distended  with  air,  as  in  Pneumothorax  which 
no  longer  sounds  tympanitic. 

Since  infiltration  of  the  parenchyma  always 
diminishes  its  power  of  contraction,  both  of  these 
conditions  must  balance;  or,  according  to  the 
magnitude  of  the  infiltration,  the  incipient  relax- 
ation of  the  thoracic  wall,  attended  with  increase 
of  the  vocal  fremitus,  must  gradually  pass  in- 
to a  diminution  of  its  power  of  vibration,  with 
cessation  of  fremitus. 

Fremitus  is  considerably  increased  over  large 
cavities  with  rigid  walls  lying  closely  against  the 
thoracic  walls. 

It  is  always  absent  in  pleuritic  exudations,  and 
is  always  increased  whenever  tympanitic  sound 
is  heard  in  the  beginning  of  Pneumonia,  and 
around  lung  tissue  so  affected,  and  also  over 
pleuritic  effusions.  It  is  usually  strengthened 
over  hepatizations,  as  long  as  they  do  not  be- 
come so  thick  as  to  interfere  with  the  vibratory 
power  of  the  chest  wall.  In  such  a  case  the  vocal 
fremitus  also  disappears.  As  long,  however,  as 


22  PERCUSSION. 

this  condition  does  not  arise,  the  presence  of  a 
distinct  fremitus  with  intense  dullness  allows  in- 
flammation of  the  parenchyma  of  the  lung  to  be 
inferred,  rather  than  pleuritis. 

When  frernitus  is  weakened  on  the  right  side, 
it  has  far  more  importance  than  when  it  takes 
place  on  the  left,  where  it  is  normally  weaker. 


AUSCULTATION. 


"We  practice  auscultation  by  listening,  either 
immediately  with  the  ear,  or  mediately  with 
a  stethoscope,  to  the  noises  or  tones  arising  in 
the  respiratory  and  circulatory  organs  in  the  per- 
formance of  their  functions,  that  we  may  judge 
thereby  of  their  anatomical  conditions. 

Auscultation  is  founded  upon  the  fact  that  in  ana- 
tomical and  physical  changes  of  affected  organs, 
the  acoustic  properties  also  assume  other  forms. 

Auscultation  of  Respiratory  Organs, 
We  divide  sounds  perceived  in  these  organs 

into: 

(1)     True  respiratory  murmurs   which    arise 

only  through  the  air,  in  its  passage  in  and  out, 

coming  in  contact  with  the  firmer  parts  of  the 

respiratory  organs;  and 

(2J     Bales,  which  arise  from  the  air  meeting 

with  fluids  while  passing  in  and  out  through  the 

air  passages. 

TRUE  RESPIRATORY  MURMURS. 

(a)  Vesicular  Respiratory  Murmur. — This 
is  similar  to  the  sound  produced  by  the  lips  in 


24  AUSCULTATION. 

drawing  in  the  air.  It  is  audible  almost  only  in 
respiration,  and  is  never  heard  in  places  other 
than  those  in  which  it  originates.  It  arises 
through  the  friction  of  the  air  against  the  walls 
of  the  fine  bronchi  and  lung  cells,  whose  con- 
tractility it  must  overcome,  and  thus  cause  them 
to  unfold. 

It  therefore  shows  that  the  air  rushes  into  nor- 
mally contractile  vesicles  of  the  part  of  the  lung 
lying  under  the  ear,  and  consequently  excludes 
all  diseases  which  relax  the  vesicles  or  make  the 
entrance  o!  air  impossible. 

Wherever  vesicular  murmur  is  heard  the  lung 
is  necessarily  healthy.  It  is  the  louder,  the  thin- 
ner the  chest  wall,  as  in  children,  the  stronger 
the  current  of  air,  and  the  greater  the  resistance 
of  the  cells,  or  when  other  parts  of  the  lung  do 
not  breathe — supplementary  vesicular  respira- 
tion. It  is  the  weaker  under  the  opposite  condi- 
tions. The  loud  vesicular  murmur  is  also  called 
puerile.  Its  absence  on  the  other  hand  never 
has  positive  meaning,  as  it  is  heard  neither  when 
the  vesicles  are  emphysematously  dilated  and 
contain  air,  when  they  are  infiltrated  and  do  not 
contain  air,  nor  when  the  bronchial  tubes  have 
become  impassible. 

A  variety  of  vesicular  respiration  is  connected 


AUSCULTATION  OF  THE  RESPIRATORY  ORGANS.     25 

with  lengthened  expiratory  murmur,  and  occurs 
in  all  conditions  which  diminish  the  volume  of 
the  bronchial  tubes,  as  in  the  case  of  swelling  of 
the  mucous  membrane,  etc. 

(6)  Bronchial  Murmur. — This  is  similar  to 
the  sound  produced  by  inspiration  and  expira- 
tion with  the  tongue  slightly  elevated  towards 
the  palate,  as  in  the  pronunciation  of  the  letter 
K.  It  is  especially  an  expiratory  murmur,  and 
arises  only  in  the  larynx  and  trachea  by  the  fric- 
tion of  the  inspired  and  expired  air  against  the 
firm  walls  of  these  parts.  It  is  therefore  always 
heard  in  the  thorax  in  other  parts  than  those  in 
which  it  arises. 

Bronchial  murmur  may  consequently  be  con- 
firmed by  auscultation  of  the  larynx  and  trachea. 
Whenever  heard  in  the  thorax,  it  shows  that  al- 
terations of  the  lungs  must  have  occurred  which 
cause  the  laryngeal  or  tracheal  respiration  to  be 
audible  to  the  distant  ear.  These  must  be  of 
such  a  nature  as  to  interfere  with  the  expansion, 
and  consequent  weakening  of  the  original  sound, 
which  occurs  in  normal  air-containing  lungs, 
naturally  bad  conductors  of  sound. 

We  find  the  necessary  conditions  when  an  air- 
containing  space,  such  as  a  bronchus  or  cavity, 
freely  communicating  with  the  larynx  and  tra- 


26  AUSCULTATION. 

chea  (the  point  of  origin),  is  surrounded  by  firm 
walls,  which  prevent  the  extension  of  sound, 
parenchyma,  for  instance,  which  has  become 
empty  of  air.  A  communicating  tube  from 
the  trachea  to  the  ear  auscultating  upon  the 
thorax  is  thus  formed,  and  conducts  the  sounds 
produced  at  one  end  unweakened  and  without 
any  disturbing  conditions  to  the  other.  Through 
this  the  sound  arising  at  the  larynx  or  trachea, 
becomes  distinctly  audible  at  the  thorax,  and 
preserves  its  original  sharp  timbre. 

Bronchial  murmur  therefore  shows  that  a 
pervious  bronchus,  or  an  air-containing  cavity,  as 
above  described,  is  situated  at  a  short  distance 
from  the  chest  wall  in  tissue  which  is  empty  of 
air,  either  by  being  completely  filled  with  firm 
or  fluid  exudations,  or  by  being  compressed 
from  without.* 

Observation. — Strong  laryngeal  or  tracheal 
murmur,  as  in  dyspnoea,  is  often  heard  on  deep 
inspiration,  even  in  lungs  containing  air,  between 
the  shoulder  blades  or  sometimes  under  the 
clavicles,  i.e.  along  the  larger  bronchial  branches. 
It  then  occurs  upon  both  sides  and  has  its  own 
peculiar,  almost  metallic  timbre.  The  strong 

*Bronchial  respiration  can  therefore  be  confirmed  by  per- 
cussion. 


AUSCULTATION  OF  THE  RESPIRATORY  ORGANS.     27 

bronchial  murmur  of  liepatized  lungs  may  some- 
times be  heard  in  healthy  lungs,  along  the  inner 
border  of  the  shoulder  blade. 

In  some  cases  a  bronchial  murmur  differing 
from  the  trachea!  sound  in  pitch,  arises  from 
the  fact  that  the  stagnated  air  of  a  bronchus, 
surrounded  by  firm  walls,  is  put  into  sonorous 
vibrations  (consonance),  by  a  current  of  air  pass- 
ing by,  as  takes  place  in  blowing  over  an  open 
key. 

Bronchial  murmur  is  heard : — 1,  over  inflamma- 
tory, tubercular  or  cancerous  hepatizations,  as 
strong  bronchial  respiration;  2,  sometimes,  but 
not  often,  over  (Edema  of  a  high  grade,  and  Hsem- 
orrhagic  Infarctions;  3,  in  compression  of  the 
lung  by  Pneumothorax,  Pyothorax  and  Hydro- 
thorax,  when  the  bronchi  remain  open,  and  then 
it  exists  as  feeble  bronchial  respiration,  which 
entirely  disappears  upon  increase  of  the  compres- 
sion; 4,  in  cavities  and  dilated  bronchi,  when  they 
are  surrounded  by  thickened  parenchyma,  as 
in  cases  where  there  is  considerable  thickening 
of  the  bronchial  walls. f 

tin  vesicular  as  in  bronchial  respiration,  inspiration  and  ex- 
piration may  follow  in  jerks  (respiration  saccadee);  showing  that 
in  the  entrance  of  the  air  into  a  part  of  the  lungs  obstructions 
occur,  which  are  gradually  overcome  in  the  progress  of  inspira- 
tion. 


28  AUSCULTATION. 

(c)  Indefinite    Respiratory  Murmur. — This    is 
similar  neither  to  the  bronchial  nor  to  the  vesi- 
cular murmur,  and  is  heard  both  upon  inspiration 
and  expiration.     It  arises  through  various  causes 
and  is  sometimes  heard  at  its  point   of   origin, 
sometimes  in  distant  places,  and  therefore  shows 
110  certain  condition  of  the  respiratory  organs. 
It  is   not  heard  in  entirely  healthy  lungs,    and 
we   therefore   search   whenever   we  find  it,  for 
other  signs  in  order  to  form  a  conclusion  con- 
cerning the  condition  of  the  lungs  and  bronchial 
tubes.     Distant  bronchial  breathing,  and  distant 
rales   lose   their  characteristic   properties,   and 
become  indefinite;  and  the  mingling  of  different 
sounds  allows  none  to  be  definitely  recognised. 
The  indefinite  respiratory  murmur  always  shows 
an  obstruction  in  the  bronchi.     The   modifica- 
tion of  the  vesicular  respiration  which  occurs 
with   strengthened   and    lengthened    expiratory 
murmur,  is  worthy  of  notice.     It  indicates  an 
obstructive   catarrh  of   the   finer   bronchi,  and 
therefore  occurs  so  often  in  the  early  stages  of 
Tuberculosis. 

(d)  The    indefinite    respiratory  murmur   often 
becomes   rattling,    ivhistling  or  hissing  when  the 
air  forces  itself  through  narrowed  places  in  the 
air  passages,  rattling  in  the  wide,  and  whistling 


AUSCULTATION  OF  THE  RESPIRATORY  ORGANS.     29 

in  the  narrow  bronchi.  This  rattling,  whistling 
or  hissing  (called  dry  rales,)  shows  nothing 
definite  concerning  the  condition  of  the  paren- 
chyma of  the  lungs.  It  is  heard  during  inspira- 
tion and  expiration,  and  distant  also  from  its 
point  of  origin.  It  is  often  spread  over  the  whole 
thorax,  and  may  be  conducted,  in  the  same 
manner  as  tracheal  murmur,  to  very  distant 
places  under  favorable  conditions.  The  vibra- 
tions which  occasion  such  sounds  may  often  be 
felt  by  the  hand.  Palpation  differentiates 
them  from  friction  sounds  through  the  fact  that 
they  are  not  limited  like  the  latter. 

Bronchitis,  Catarrh  and  swelling  of  the  mu- 
cous membrane  produce  these  modifications  of 
the  indefinite  murmur,  and  thereby  only  too 
often  render  it  impossible  to  determine  whether 
air  enters  the  vesicles  or  not. 

RALES. 

These  usually  resemble  the  sounds  made  by 
the  bursting  of  the  bubbles  of  a  fluid.  Some- 
times they  resemble  the  creaking  of  leather,  or 
the  rumpling  of  paper.  The  former,  which  are 
called  the  moist,  gradually  shade  into  the 
latter.  They  show  one  difference,  namely,  that 
the  air,  inspired  and  expired  in  breathing,  forces 


30  AUSCULTATION. 

itself  through  fluid  in  its  passage.  They  are  the 
dryer,  the  tougher  the  fluid  through  which  the 
air  forces  itself,  and  the  more  numerous,  the 
more  fluid  there  is.  Rale«  may  be  classified  as 
follows : 

(a)  Vesicular  Hales. — By  these  we  know  that 
the  vesicles  forced  open  are  small  and  of  uni- 
form size.  They  may  be  heard  during  inspiration 
or  expiration,  or  during  both.  Bales  with  very 
small  bubbles  can  be  formed  only  in  the  finest 
bronchi  and  in  the  air  cells.  Vesicular  rales, 
therefore,  arise  when  the  air  in  these  parts  en- 
counters fluids.  They  show  that  air  still  forces 
itself  into  the  lung  vesicles  under  the  ear,  and 
consequently,  have  in  this  respect  the  same 
meaning  as  vesicular  murmur.  But  they  show, 
furthermore,  that  these  parts  are  filled  with  fluid. 

We  hear  moist  vesicular  rales  when  the  lung 
cells  are  oedematously  infiltrated,  and  dry  rales 
when  they  contain  coagulable  exudations,  as  in 
the  first  and  last  stages  of  Pneumonia,  and  recent 
Pulmonary  Haemorrhage. 

(fr)  The  bronchial,  or  so  called  consonant  rales 
of  Skoda.  These  are  recognized  by  being  loud, 
high,  and  ringing  in  character,  not  uniform  in 
their  bubbles,  and  accompanied  by  resonance. 

Kinging  Rales,  whose  bubbles  are  not  uniform, 


AUSCULTATION  OF  THE  RESPIRATORY  OKGANS.    31 

can  occur  only  in  large  spaces  partially  filled 
with  fluid,  in  which  the  air  moves,  as  large 
bronchi  and  cavities.  In  the  healthy  thorax 
they  can  be  heard  only  at  a  distance  from  their 
point  of  origin,  and  consequently  sound  only 
dull  and  deep.  Whenever  they  are  heard  clear, 
high,  and  ringing  in  the  thorax,  they  show, 
either  that  just  underneath  the  chest  there 
exists  a  cavity  containing  fluid  into  which  air 
enters  and  from  which  it  is  expelled;  or,  that 
the  changes  which  bronchial  murmur  indicates 
must  have  taken  place.  In  this  case  the  clear 
and  high  pitch  rales,  whose  bubbles  are  not 
uniform,  arising  in  the  larger  bronchi  es- 
pecially, must  be  conducted  undiminished  to  the 
periphery.  They  therefore  indicate  the  same  con- 
ditions as  the  bronchial  murmur,  and  also  that 
fluids  exist  in  the  larger  air  passages  at  the  same 
time. 

Tubercular  infiltrations,  cavities,  and  hepatiza- 
tions  usually  allow  bronchial  rales  to  be  heard 
when  fluids  exist  in  the  large  bronchi.  The 
more  ringing  and  the  drier  the  rales,  the  more 
probable  is  it  that  they  arise  in  cavities.  They 
therefore,  with  few  exceptions,  indicate  advanced 
Tuberculosis. 

(c)     Indefinite  Hales. — To    this  class    belong 


32  AUSCULTATION. 

all  rales  which  are  not  distinctly  vesicular  or 
bronchial.  They  appear  dull,  deep  and  dissimi- 
lar in  the  size  of  their  bubbles,  and  without  re- 
sonance. Since  they  arise  from  the  most  different 
conditions  of  the  lungs,  they  indicate  no  definite 
alteration.  They  merely  show  the  presence  of 
fluids  in  general  in  the  air  passages. 

With  normal  percussion  they  lead  us  to  infer 
catarrhs!  affection  of  the  bronchi. 

Observation. — Very  fine  crepitant  rales,  con- 
stant only  during  inspiration,  and  similar  to 
the  sound  produced  by  the  rubbing  together  of 
dry  hairs,  are  caused  by  the  air  forcing  itself 
into  the  finest  bronchi  and  lung  vesicles,  whose 
opposite  walls  are  made  adherent  by  a  tough 
exudation.  (Wintrich.)  They  indicate  the  pri- 
mary stage  of  Pneumonia,  but  are  also  often 
heard  in  healthy  lungs,  after  persons  have  been 
long  in  the  recumbent  posture  and  fully  expand 
their  lungs  again  for  the  first  time  by  a  deep  in- 
spiration. 

Auscultation  of  the  Voice. 

In  the  auscultation  of  the  voice  we  observe 
the  following  abnormalities : 

1.  Simple  Bronchopliony .  (Weak  broncho- 
phony  of  Skoda.) — In  this  the  vocal  tones  are 


f    VNIYER 

• 

AUSCULTATION  OF    THE  VOICE.  33 

audible  at  the  thorax  as  voice,  but  are  not  ac- 
companied by  any  vibration  of  the  inner  ear. 
The  voice,  which  is  formed  in  the  larynx  alone, 
can  be  distinctly  heard  at  the  thorax  as  voice, 
only  when  the  regular  laryngeal  vibrations  can 
be  completely  conducted  to  the  auscultated  point 
of  the  periphery  through  an  air  tube.  Broncho- 
phony  takes  place,  therefore,  when  the  conditions 
of  bronchial  murmur  are  present. 

It  has  the  same  meaning  as  bronchial  respi- 
ration, serves  to  control  its  correct  interpreta- 
tion, generally  arises  earlier,  and  is  usually 
also  audible  in  compression  of  the  lung  by 
exudations. 

(2)  Strong  Bronchophony ,  Pectoriloquy. — In 
this  the  voice  sounds  as  if  articulated  imme- 
diately into  the  ear.  It  is  accompanied  by 
concussion  of  the  ear  and  through  this  has  tone. 
It  arises  when  the  conditions  are  especially 
favorable  for  the  undiminished  conduction  of 
the  voice,  i.  e.  when  the  sound-conducting  tubes 
either  diminish  regularly  in  size,  or  end  in  ir- 
regular cavities.  In  the  first  case  through  the 
continued  condensation  of  the  progressing  sound 
waves,  and  in  the  second,  through  a  similar  oper- 
ation of  direct  and  reflected  waves,  an  augmen- 
tation of  the  original  sound  can  arise. 
3 


34  AUSCULTATION, 

When  strong  bronchophony  is  heard  over  a 
large  extent,  an  inflammatory  hepatization  has 
probably  occurred.  In  tuberculous  lungs  the 
points  where  cavities  are  situated  oftentimes 
cause  distinct  pectoriloquy. 

(3)  Indistinct   humming    or    total    absence  of 
the  voice  arises  in  normal  lungs,  but  also  in  any 
disease  in  which  one  of  the  conditions  of  bron- 
chophony is  absent.     It  therefore  has  no  defi- 
nite signification.  x 

(4)  JEgophony. — The   voice   has     a   peculiar 
tremulous  character.     It   has  the  same  signifi- 
cance as  bronchophony,  with  which  it  may  be 
heard  alternately  at  one  and  the  same  place. 

Peculiar  modifications  of  the  phenomena  of 
auscultation  are : 

Amphoric  resonance  and  metallic  ringing  of 
the  respiratory  murmur,  and  rales  as  well  as  of 
the  voice. 

They  may  be  imitated  by  speaking  or  blowing 
into  a  vessel.  In  this  besides  the  original 
sound,  an  echoing  hum,  or  even  single,  ringing^ 
high  pitched  tones  are  perceived. 

They  arise  whenever  separately  sounding 
vibrations  and  independent  acoustic  phenomena 
are  produced  in  a  large  space  containing  air, 
with  walls  capable  of  reflecting  sound  by  the  en- 


AUSCULTATION  OF  THE  VOICE.  35 

trance  of  the  sonorous  waves  of  bronchial  res- 
piration, rales  or  bronchophony. 

They  indicate  either  large  cavities  or  Pneumo- 
thorax.  Eespiratory  murmurs  more  frequently 
cause  amphoric  resonance,  while  rales  and 
speaking  produce  metallic  ringing.  In  order 
that  these  phenomena  should  occur  in  Pneumo- 
thorax  a  free  communication  with  a  bronchus  is 
unnecessary.  Sometimes  only  short,  high  sounds 
caused  by  single  rales  are  heard  with  each  in- 
spiration and  expiration.  They  were  formerly 
incorrectly  ascribed  to  the  falling  of  drops. 

Friction  Sounds. — These  usually  resemble 
the  sounds  produced  by  rubbing  the  dry  surfaces 
of  the  hand  against  each  other,  or  that  occa- 
sioned by  the  creaking  of  leather.  In  the  latter 
case  they  very  much  resemble  dry  rales,  but  are 
as  well  felt  as  heard,  which  is  not  the  case  with 
rales.  Friction  sounds  are  usually  audible  dur- 
ing both  inspiration  and  expiration. 

They  arise  in  roughening  of  the  pleura  or  the 
pericardium,  when  the  performance  of  the 
function  of  the  lungs  or  heart  occasions  a  move- 
ment of  their  opposite  layers.  With  few  excep- 
tions, they  indicate  inflammations  of  the  serous 
membranes  within  the  thorax. 

Recent  Pleuritis  and  Pericarditis  cause  fric- 


36  AUSCULTATION. 

tion  sounds  as  long  as  fluid  exudations  do  not 
separate  the  serous  layers  from  each  other.  In 
the  cardiac  sac  a  considerable  quantity  of  fluid 
does  not  always  hinder  their  occurrence.  More 
frequently  friction  sounds  occur  in  the  pleura 
or  pericardium  after  resorption,  until  union  or 
smoothing  has  taken  place. 

Auscultation  of  the  Circulatory  Organs. 
In  all  acoustic  phenomena  in  the  circulatory 
apparatus  a  vibratory  body,  (valves  and  tube 
walls,)  and  the  force  producing  vibration,  (the 
moving  blood,)  come  into  consideration.  If  the 
vibrations  are  regular  a  tone  arises;  if  they 
become  irregular  or  unequal  through  disturb- 
ance of  one  of  the  two  factors,  a  murmur  occurs. 
On  the  other  hand,  circumstances  may  arise 
which  render  processes  appreciable  to  the  ear, 
which  normally  are  inaudible. 

CARDIAC  SOUNDS. 

We  hear  two  tones  in  the  cardiac  region  dur- 
ing a  ventricular  systole  and  diastole,  which 
indicate  alternate  conditions  of  the  heart.  The 
most  probable  theory  of  their  origin  is  the 
following : 

The  first  tone,  accompanying  the  systole  and 


AUSCULTATION  OF  THE  HEART.  3  7 

the  cardiac  impulse,  lasts  as  long  as  the  systole. 
It  is  produced  in  both  ventricles  by  the  concus- 
sion caused  by  the  systolic  pressure  of  the 
blood  in  the  venous  valves  closed  at  the  end  of 
the  contraction  of  the  auricle,  and  stretched 
during  its  diastole.  It  is  also  produced  in  the 
arteries  by  the  vibrations  of  their  walls  made 
tense  by  systole.  These  vibrations  are  syn- 
chronous with  the  pulse. 

The  second  tone,  accompanying  the  diastole, 
clearer,  higher  and  shorter  than  the  first,  arises, 
on  the  other  hand,  only  at  the  point  of  origin  of 
the  arteries.  It  is  formed  by  the  vibrations  of 
the  semi-lunar  valves,  because  with  the  close  of 
the  systole,  the  arterial  column,  brought  under 
greater  pressure  by  the  tension  of  the  arteries, 
forces  the  valves  against  the  ostium  and  sets 
them  into  sonorous  vibrations.  Itisthelonderthe 
fuller  the  arteries,  therefore  the  stronger  the 
impulse  producing  the  shock. 

We  obtain  six  cardiac  tones  in  the  following 
manner:  The  first  sounds  are  double  as  well  in 
the  ventricle  as  in  the  vessels.  The  second 
sounds  arise  only  in  the  vessels  and  are  there- 
fore conducted  when  they  are  heard  in  the 
region  of  the  valves.  (Bamberger.) 

According  to  Skoda,  two  sounds  occur  in  each 


38  AUSCULTATION. 

ventricle  and  blood-vessel,  so  that  in  all  eight 
tones  are  formed. 

Kapp,  Kiwisch,  and  Nega  accept  only  four 
tones,  the  first  two  arising  in  the  ventricles,  the 
last  two  in  the  vessels. 

The  accentuation  ( —  ^J)  falls  upon  the  first 
sound  in  both  ventricles  ;  over  the  aorta  and 
pulmonary  artery,  on  the  other  hand,  it  falls 
upon  the  second  sound. 

When  we  hear  tones  at  the  heart  it  shows 
that  the  functions  of  the  muscles  of  that  organ 
are  performed  regularly,  and  that  the  structure 
of  the  valves  is  such  that  they  are  closed  at  the 
right  time  and  can  vibrate  properly. 

The  best  spot  for  the  auscultation  of  the 
pulmonary  artery  is  at  the  second  left  intercostal 
space,  |  to  1  inch  from  the  border  of  the  sternum. 

The 'sounds  and  murmurs  of  the  aorta  are 
best  heard  when  the  stethoscope  is  placed  upon 
the  third  right  costal  cartilage. 

For  the  mitral  valve  the  position  of  the  apex 
beat  is  the  best. 

For  the  tricuspid,  the  best  position  is  at  the 
insertion  of  the  fourth  rib  into  the  left  inferior 
border  of  the  sternum. 

CARDIAC   MURMUR. 

In  some  anomalies  of  the  activity  of  the  heart 


AUSCULTATION  OF  THE  HEART.  39 

and  in  anatomical  changes  of  its  valves,  we  hear 
murmurs  instead  of  the  cardiac  sounds,  or  to- 
gether with  them.  Not  from  their  nature,  but 
from  the  time  of  their  appearance,  and  their 
distinctness  to  the  ear,  can  conclusions  be  formed 
concerning  the  lesions  of  the  heart. 

Cardiac  murmurs  arise  instead  of  cardiac 
tones,  when  the  valves  no  longer  form  regular 
tones  by  the  vibrations  produced,  or  together 
with  them  when  new  formations  occur  in  the 
heart,  which  can  set  the  blood  into  audible  vi- 
brations. To  their  conditions  therefore  belongs, 
besides  the  anatomical  changes,  also  sufficient 
rapidity  of  the  current  of  blood.  Abnormal 
composition  of  the  blood  in  Anaemia,  or  Chlorosis 
cannot  alone  induce  murmurs,  except  indi- 
rectly through  its  influence  upon  nutrition  and 
thereby  upon  the  tension  and  tonicity  (power  of 
vibration)  of  the  valvular  apparatus.  Hence 
such  murmurs  arise  only  at  the  bicuspid  valves, 
in  the  performance  of  whose  functions  the  mus- 
cles operate. 

Murmurs,  therefore,  generally  show  that  the 
valves,  from  some  cause  or  other,  are  no  longer 
capable  of  proper  tension  or  closure,  or  that 
upon  the  endocardium,  within  which  the  cur- 
rent of  blood  has  a  sufficient  rapidity,  deposits 


40  AUSCULTATION. 

capable  of  vibration  have  formed,  especially  at 
the  ostia.  Cardiac  murmurs  indicate  insuf- 
ficiency or  stenosis  of  the  valves. 

In  such  cases  the  murmurs  are  permanent,  and 
must  be  distinguished  from  temporary  murmurs. 
The  latter  show  that  the  functions  of  the  papil- 
lary muscles  are  interfered  with,  from  disturb- 
ance of  their  innervation. 

Murmurs*  arise  with  or  instead  of  systolic 
sounds,  synchronous  with  the  carotid  and  radi- 
al pulse. 

SYSTOLIC   MURMURS. 

According  to  their  intensity  at  different  points, 
we  have  drawn  the  following  conclusions  from 
the  systolic  murmurs : 

(1)  Systolic  murmurs  whose  greatest  inten- 
sity corresponds  with  the  position  of  the  apex 
beat,  only  slightly  audible  along  the  aorta,  in- 
dicate  either  considerable  mitral  insufficiency, 
causing  increase  of  the  second  pulmonary  sound, 
or  roughness  upon  the  mitral  valve. 

(2)  Systolic   murmurs  having  their  greatest 
intensity  at  the   lower  end  of   the  sternum,  as 

*Gendrin  distinguishes  presystolic,  systolic,  and  perisystolic 
and  likewise  pre-diastolic,  diastolic  and  peridiastolic  murmurs. 
Nevertheless  it  is  important  only  to  determine  whether  a  mur- 
mur is  systolic  or  diastolic. 


AUSCULTATION  OF  THE  HEABT.  41 

high  as  the  insertion  of  the  fourth  rib,  indicate  tri- 
cuspid  insufficiency.  However,  the  greater 
number  of  sounds  heard  here  are  occasioned  by 
abnormal  pressure  of  blood. 

(3)  Systolic   murmurs  at    the   right   of   the 
sternum,  as  high  as  the  second  and  third  ribs, 
denote  stenosis  of  the  aortic  orifice. 

(4)  Systolic    murmurs    in    the    second    left 
intercostal  space,  in  very  rare  cases  are   occa- 
sioned  by   stenosis   of  the   pulmonary   orifice. 
They  are  usually  the  so-called  anaemic  murmurs. 

Systolic  murmurs  are  formed  temporarily, 
without  any  organic  change,  in  Anaemia,  Chloro- 
sis, and  severe  blood  diseases.  They  are  called 
anaemic,  or  better,  accidental  murmurs.  (Bam- 
berger.)  They  are  never  diastolic,  have  a  weak, 
blowing  character,  and  never  mask  the  systolic 
sound.  They  are  furthermore  equally  audible 
in  all  parts  of  the  heart.  Venous  murmurs 
occur  synchronously,  which  is  never,  or  only 
seldom,  the  case  in  valvular  defects. 

With,  or  instead  of,  the  second  diastolic 
sound,  we  sometimes  have : — 

DIASTOLIC   MURMURS. 

(1)  Diastolic  murmurs  having  their  greatest 
intensity  at  the  apex  beat  indicate  stenosis  of 
the  left  venous  orifice. 


42  AUSCULTATION. 

(2)  Diastolic   murmurs  at   the   lower  end  of 
the  sternum  show  stenosis  of  the  right  venous 
orifice,  which  is  very  rare. 

(3)  Diastolic    murmurs  on  the   right  of  the 
sternum,  in  the  region  of  the  2d  or  3d  rib,  indi- 
cate insufficiency  of  the  aortic  valves. 

(4)  Diastolic  murmurs  in  the  second  left  inter- 
costal space  indicate  insufficiency  of  the   pul- 
monary valves. 

For  the  confirmation  of  the  diagnosis  of  a 
valvular  lesion,  besides  the  facts  obtained  by 
auscultation,  those  not  so  obtained  are  of  espe-. 
cial  value,  namely,  the  consequences  of  the  sin- 
gle cardiac  defect,  which  vary  according  to  the 
locality  of  the  lesion.  Their  determination 
always  serves  to  confirm  the  auscultatory  diag- 
nosis, and  has  great  value  in  doubtful  cases.  In 
numerous  combinations  of  different  cardiac  de- 
fects, they  may  alone  give  the  decision.  The 
consequences  of  single  cardiac  defects  considered 
by  themselves  are : 

(1)  Mitral  insufficiency. — The  blood  regurgi- 
tates with  each  systole  into  the  left  auricle,  fills 
this  inordinately,  then,  as  well  as  during  the  suc- 
ceeding diastole  of  the  ventricle.  This  after- 
wards produces  dilatation  and  hypertrophy  of 
the  left  heart.  Then  obstruction  of  the  pul- 


AUSCULTATION  OF   THE  HEART.  43 

monic  circulation  with  all  its  consequences 
occurs — Catarrh,  (Edema  and  Hsemorrhagic 
Infarctions.  As  soon  as  the  lungs  become  very 
much  affected,  the  obstruction  acts  upon  the 
right  heart,  which  dilates  and  hypertrophies. 
Venous  pulsation  in  the  neck  and  increase  of  the 
systemic  circulation  are  also  observed. 

The  signs  are :  increased  and  extended  apex 
beat,  moderately  large  and  usually  weak  pulse, 
uniform  extension  of  the  heart  upon  percussion, 
strengthening  of  the  second  pulmonary  sound, 
appreciable  as  a  diastolic  beat  in  the  second  left 
intercostal  space,  systolic  murmurs  at  the  apex 
instead  of  the  first  sound,  and  venous  pulsation. 

(2)  Mitral  stenosis. — The  left  ventricle  re- 
ceives less  blood  and  consequently  becomes 
atrophied.  Otherwise  we  have  the  same  symp- 
toms as  in  (1),  only  arising  much  more  rapidly. 

The  apex  beat  is  extended  towards  the  right, 
is  moderately  strong,  and  not  appreciable  on 
the  left  side.  The  pulse  is  very  weak  and 
small.  Diastolic  fremissement  cataire  occurs  at 
the  nipple,  and  diastolic  murmurs  at  the  apex 
beat.  The  cardiac  dullness  has  extended  to  the 
right.  As  a  rule  we  have  more  or  less  systolic 
murmur  accompanying  it.  The  first  sound  in 
the  aorta  is  feeble  and  the  second  in  the  pul- 
monary artery  is  increased. 


44  AUSCULTATION. 

(3)  Tricuspid  Insufficiency. — The  shock  is  not 
strengthened,  the  pulse   is  unchanged,  and  the 
cardiac  dullness  is  extended  to  the  right.     On 
the  right  we  have  systolic  murmurs  at  the  lower 
part  of  the  sternum. 

(4)  Tricuspid  Stenosis. — This  seldom  occurs. 

(5)  Insufficiency  of  Aortic  Valves. — The    left 
ventricle   receives    a   stream    of    blood  during 
diastole,    simultaneously  from    the   auricle  and 
by  regurgitation  from  the  aorta,  and  thereby  di- 
latation and  hypertrophy  are    caused.     On  ac- 
count of  the  longer  resistance  of  the  mitral  valve, 
disturbance   of    both    circulations   takes  place 
later. 

The  shock  is  very  extensive  and  strong,  espec- 
ially to  the  left  and  upwards.  There  is  consid- 
erable increase  of  the  region  of  cardiac  dullness, 
the  arteries  are  dilated,  and  the  pulse  is  large, 
hard,  and  twittering  (jumping  pulse).  Diastolic 
murmurs  in  the  left  ventricle  and  aorta  are 
mostly  audible  for  some  distance  in  the  arteries. 
(6)  Stenosis  of  the  Aortic  Valves.  This 
seldom  occurs  without  simultaneous  insuffi- 
ciency. Hypertrophy  of  the  left  ventricle  is 
produced.  The  shock  is  not  strengthened,  the 
pulse  is  small,  and  the  cardiac  dullness  exten- 
ded. Systolic  murmurs  occur  in  the  ventricle 


AUSCULTATION  OF  THE  HEAET.  45 

and  arteries,  with  a  feeble  second  sound  in  the 
aorta,  on  account  of  the  slight  tension  of  its 
walls. 

(7)  Insufficiency,  and  (8)  Stenosis  of  the  pul- 
monary artery  rarely  occur. 

PERICARDIAL  MUKMUES. 

These  are  produced  by  roughening  of  the 
pericardium,  and  are  distinguished  from  endo- 
cardial  murmurs  by  the  fact  that  they  do  not 
occur  exactly  with,  or  much  less  instead  of,  the 
cardiac  sounds.  They  are  limited  and  may  be 
increased  by  external  pressure.  Even  when  of 
considerable  intensity  they  are  not  conducted 
from  their  point  of  origin.  Change  of  position 
of  the  patient  renders  the  murmur  louder  and 
alters  its  locality. 

It  is  distinguished  from  the  pleuritic  friction 
sound  by  the  fact  that  the  latter  disappears  up- 
on cessation  of  breathing. 

If  the  murmurs  are  stronger  they  have  the 
character  of  gen  tie  rubbing,  scraping,  scratching, 
or  crackling.  The  last  modification  may  be  felt 
by  the  hand,  while  the  endocardial  murmurs 
more  closely  resemble  breathing  or  blowing. 

They  indicate  Pericarditis,  either  incipient  or 
advanced. 


46  AUSCULTATION. 


APEX  BEAT. 

This  appears  normally,  during  systole  of  the 
ventricle,  at  the  fifth  intercostal  space,  below  and 
internal  to  the  nipple. 

Various  opinions  prevail  concerning  its  origin. 

(1)  The  Lever  movement  hypothesis  of   Kiir- 
schner  is  founded   upon  the  acceptation  of  the 
fact   that   the  heart,  during   systole,  performs 
rising  lever  movement  against  the  nipple,  where- 
by the   distance   traversed   by  the  apex,  as  the 
furthest  point  of  the  lever,  is  greatest,  thus  caus- 
ing the  impulse.     This  is  incorrect,  because  the 
lower   part  of   the  heart  lies  firmly  against   the 
chest-wall  and  can  neither  leave  nor  approach  it. 
If  the  impulse  be  visible  in  several   intercostal 
spaces,  it  always  appears  sooner  in  the  one  above, 
whereas,  in  lever  movement  the  reverse  would 
take  place. 

(2)  The  Rebounding  theory  of  Gutbrod  and 
Skoda  considers  the  action  of  the  heart  analogous 
to  the  repulsion  of    a  gun    in    shooting.     The 
rebounding    of    the  heart,  in    accordance  with 
this   theory,    is    occasioned  by  the  flowing    of 
blood  from  the  aortic  orifice  causing  an  opposite 
motion  in  the  apex.     We  must  consider  that  the 
force  of  repulsion  is  produced  by  the  contrac- 


- 

OF   THE  HEART.  47 

tion  of  the  ventricle,  and  the  difference  between 
the  two  is  to  be  decided.  According  to  Bam- 
berger,  the  latter  element  preponderates,  and 
consequently  repulsion  is  impossible.  Analogy 
with  the  evacuation  of  other  hollow  muscles, 
as  the  urinary  bladder,  does  not  allow  such  an 
admission  to  be  made. 

(3)  According  to  Kiwsich  and  Bamberger  the 
shock  is  caused  by  the  systolic  hardening  and 
arching  of  the  apex  alone.  Since  the  longitudi- 
nal diameter  of  the  heart  is  diminished  during 
systole,  this  defect  must  be  compensated  for  by 
the  systolic  elongation  of  the  larger  vessels, 
which  produces  a  movement  to  the  left  and 
downwards. 

The  apex  beat  is  the  safest  sign  of  the  time 
of  systole.  The  following  anomalies  of  the 
apex  beat  occur : 

(a)  When  it  appears  in  more  than  two  inter- 
costal spaces  at  most,  and  more  than  2  c.  m.  in 
its  greatest  breadth,  it  proves  hypertrophy  of 
the  heart. 

(fe)  It  may  be  weaker,  as  in  pericardial  and 
slight  left  pleuritic  exudations,  as  long  as  the 
heart  is  not  compressed,  in  union  of  the  heart 
with  the  pericardium,  in  Emphysema  of  the  left 
lung,  and  in  Atrophy  of  the  heart;  or  it  may  be 


48  AUSCULTATION. 

stronger  and  then  produces  shock  and  elevation, 
as  in  Hypertrophy  with  Dilatation  of  both  ven- 
tricles. 

(c)  The  apex  beat  may  be  changed  in  posi- 
tion. It  is  found  at  the  lower  portion  of  the 
sternum,  at  the  pit  of  the  stomach,  in  vertical 
elongation  of  the  heart  through  extensive  exu- 
dations, Pneumothorax,  or  Emphysema  of  the 
left  lobe  of  the  lungs.  It  is  seen  further  to  the 
left,  and  higher  than  normal,  in  horizontal  posi- 
tion of  the  heart.  This  arises  when  the  dia- 
phragm is  driven  higher  in  the  thoracic  cavity,  on 
the  left  side,  as  in  extensive  exudations  into  the 
abdomen,  Tympanites,  and  enlargement  of  the 
left  lobe  of  the  liyer.  It  also  arises  in  exten- 
sive exudations  into  the  right  side  of  the  chest, 
whereby  the  whole  liver  is  forced  to  the  left, 
and  the  left  lobe  upwards.  It  is  found  displaced 
to  the  left  and  downwards  in  hypertrophy  of 
the  left  vetricle,  and  elongation  of  the  ascend- 
ing aorta, 

Fremissement  Cataire. — This  consists  of  a  feel- 
ing of  light  and  gentle  trembling,  as  of  a  purring  - 
cat,  upon  any  point  of  the  cardiac  region.     It  is 
not  similar  to  a  palpable  murmur,  but  like  this 
may  have  a  varying  point  and  time  of  appearance. 

Bystollcfremissementcataire  in  the  region  of  the 
apex  beat  indicates  mitral  insufficiency.     In  the 


AUSCULTATION  OF  BLOOD  VESSELS.  49 

upper  part  of  the  sternum,  about  the  third  rib,  it 
indicates  stenosis  of  the  aorta.  Diastolic  fremisse- 
ment  cataire  at  the  apex  beat  indicates  mitral 
stenosis,  and  at  the  upper  part  of  the  sternum, 
about  the  third  rib,  insufficiency  of  the  aortic 
valves. 

Fremissement  Cataire  which  extends  over  the 
entire  cardiac  region,  indicates  extensive  le- 
sion of  several  valves,  abnormal  communication 
of  the  cavities  of  the  heart,  or  communication  of 
an  aortic  aneurism,  with  a  cavity  of  the  heart  or 
with  a  large  vein. 

Division  of  the  cardiac  sounds.  The  physical 
reason  of  this  is  as  yet  unknown.  One  of  the 
cardiac  sounds  seems  to  be  divided  into  two  or 
three  short  sounds,  which  follow  each  other  very 
rapidly.  This  appears  most  frequently  in  the  sec- 
ond sound,  which  thereby  receives  the  following 

turn  tr-m  turn  tr-r-rm 
1212 

Clique  Metattique,is  a  clanging  systolic  sound, 
occurring  frequently  in  hypertrophy.  The  clang- 
ing probably  arises  froin  the  concussion  of  the 
thorax. 

Auscultation  of  Blood  Vessels. 
Arteries. — Under  normal  circumstances,  when 
we  carefully  auscultate  arteries  without  pressure, 


50  AUSCULTATION. 

we  hear  an  indistinct  sound  corresponding  with 
the  pulse.  It  is  only  near  the  heart  that  we  hear 
another,  the  conducted  diastolic  valvular  sound. 

Arterial  murmurs  arise  through  irregular  vi- 
bration of  the  vascular  walls,  as  the  tone  does 
through  the  regular,  the  impulse  being  supplied 
either  by  the  gentle  or  more  rapid  current  of  the 
blood.*  Arterial  murmurs  are  recognizable  by 
the  fact,  that  they  are  intermittant  and  synchro- 
nous'with  the  pulse. 

It  has  been  proved  experimentally,  that  any 
constriction  of  the  vascular  walls,  in  whatever 
way  produced,  so  that  the  stream  passes  from  a 
narrower  part  of  its  bed  into  a  wider  one  with 
sufficient  rapidity  to  cause  murmurs,  produces 
them  at  and  behind  the  constricted  point.  Rough- 
ness of  the  inner  wall  of  the  vessel  of  itself 
causes  no  murmur,  but  it  assists  their  formation 
under  the  above  named  circumstances. 

The  arterial  murmurs,  near  the  heart,  like  the 
so  called  systolic  cardiac  murmurs  over  the 
arteries  , indicate  stenosis  of  the  arterial  orifices; 
at  a  distance  from  the  heart  they  show  compres- 
sion of  the  auscultated  artery,  with  very  few  ex- 

*When  the  walls  of  the  vessels  are  entirely  rigid,  any  acous- 
tic phenomena  are  impossible. 


AUSCULTATION  OF  BLOOD  VESSELS.      51 

ceptions.  In  the  latter  case,  they  may  be  pro- 
duced by  the  stethoscope  in  superficial  arteries, 
by  the  action  of  muscles,  as  occurs  in  the  neck  in 
twisting  the  head,  or  by  tumors,  Struma,  lym- 
phatic tumors,  enlarged  uterus,  etc. 

The  most  important  of  all  is  the  so  called 
placental  murmur,  which  arises  by  the  compress- 
ion of  the  iliac  or  hypogastric,  seldom  of  the 
epigastric,  artery  by  the  distended  uterus. 

More  rarely  do  spontaneous  arterial  murmurs 
arise  through  disturbance  of  the  innervation  or 
nutrition  of  the  walls,  which  produce  an  irregular 
lumen,  as  in  convulsive  conditions,  Anaemia, 
Typhoid  Fever,  and  Chlorosis. 

In  aneurisms  the  occurrence  of  murmurs 
likewise  depends  upon  the  rapidity  of  the  current 
of  blood  and  the  change  of  lumen. 

Veins. — In  the  veins,  under  normal  circumstan- 
ces, no  acoustic  phenomena  are  produced. 

Murmurs  arise  under  the  same  conditions  as 
in  arteries.  They  presuppose  an  increased  rap- 
idity of  the  current  and  an  inequality  of  lumen. 
They  may  be  recognized  by  the  fact  that  they 
are  continuous,  or  are  increased  during  inspira- 
tion, and  often  sound  musical. 

The  veins^of  the  neck,  almost  exclusively,  have 
sufficient  rapidity  to  render  the  murmurs  every- 


52  AUSCULTATION. 

where   possible;    their  presence,  therefore,  ex- 
cludes obstruction  of  the  venous  circulation. 

They  are  also  usually  first  produced  by  a 
compression  of  the  veins  of  the  neck,  by  the 
stethoscope,  or  by  twisting  of  the  head,  which 
permits  the  bruit  de  diable  to  be  heard  in  almost 
all  healthy  persons.  The  above  mentioned 
elements  operate  the  easier,  the  more  liquid  the 
blood,  and  the  less  tonicity  the  venous  walls 
possess.  In  this  lies  their  relationship  to  Chlo- 
rosis and  Anaemia. 

Foetal  Pulsation. 

We  hear  this  usually  in  the  median  line  between 
the  navel  and  the  symphysis,  and  refer  it  to  the 
cardiac  sounds  of  the  foetus.  It  is  heard  after 
the  sixth  month  of  pregnancy,  and  is  a  certain 
sign  that  the  child  lives.  Sometinies  we  may 
recognise  twins  through  it,  when  the  two  hearts 
do  not  beat  simultaneously.  If,  after  repeated 
examinations  in  advanced  pregnancy,  the  sound 
has  not  been  heard,  we  may  infer  the  death  of 
the  child. 


INDEX. 


PAGE. 

^Egophony 34 

Amphoric  resonance 34 

Apex  beat    46 

"     "     anomalies  of 47 

Auscultation,  method  of  performing 23 

' '            of  arteries 49 

"             "  blood  vessels  49 

' '  circulatory  organs 36 

' '  respiratory  organs 23 

'             "  veins 51 

"              ' '  voice 32 

Bronchial  murmur 25 

rales , 30 

Bronchophony 32 

Bruit  de  diable 52 

"     "  pot  felt 14 

Cardiac  dullness f 16 

"      diminished 17 

' '      increased ....  17 

1 '        murmurs  38 

' '        sounds 36 

"       divison  of 49 

' '        vacuum 16 

Clique  metallique 49 

Cracked  metal  sound 14 

Crepitant  rales 32 


INDEX. 

Diastolic  murmurs 41 

' '        fremissement  cataire 49 

Division  of  cardiac  sounds 49 

Dull  sound 6 

Effects  of  aortic  insufficiency ,  44 

"       "       "      stenosis 44 

"       "  mitral  insufficiency  .. 42 

"       "         *'     stenosis 43 

1 '       tricuspid  insufficiency 44 

Foetal  pulsation 52 

Fremissement  cataire 48 

"                  "     diastolic 49 

"                  "      systolic 48 

Fremitus 20 

Friction  sounds 35 

Heart,  percussion  of 15 

Indefinite  rales 31 

"        murmur 28 

Laryngeal  murmur .  26 

Liver,  percussion  of :  , 17 

Lung,                        ' ' 15 

Mammary  line 5 

Metallic  ringing 13 

Murmur,  arterial 50 

' '        bronchial 25 

' '        cardiac   ,  : . , , 38 

' '         diastolic 41 

' '         indefinite 28 

4 '         laryngeal 26 

' '        pericardial 45 

' '         placental 51 

' '         systolic , 40 

"         tracheal 28 

*  •        vesicular 23 


INDEX. 

Non  tympanitic  sound 8 

Parasternal  line 5 

Pectoriloquy 33 

Percussion,  method  of  performing 5 

of  heart 15 

"    liver 17 

' '           "    lung 15 

' '    spleen 18 

palpatory ...    . . .  19 

Respiration  saccadee 26 

Kales 29 

' '    bronchial          30 

' '     crepitant 32 

"     indefinite , 31 

',     vesicular 30 

Sound,  dull 6 

' '      friction 35 

' '      non  tympanitic 7 

' '       sonorous 6 

muffler  of 12 

"      tympanitic 7 

Spleen,  percussion  of 18 

Tracheal  murmur 26 

Tympanitic  sound 7 


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